The concept of half exterior and half interior constitutes an important Jing Fang philosophy. The half exterior and half interior yang pattern is Shao Yang disease while the half exterior half interior yin pattern is associated with Jue Yin diseases. Relevant treatment of disorder of the half exterior and half interior is “harmonizing” strategy.
As for the complicated miscellaneous pattern which would be difficult to base the treatment in accordance with the relevant outline of the Six Channels, one can adopt the process of elimination method in other words one needs to preclude exterior pattern and interior patterns and what is remaining should be the half exterior and half interior pattern. To refine the diagnosis, one must further differentiate heat and cold as well as deficiency and excess to distinguish the difference between a yang pattern and a yin pattern to be followed by formula pattern identification.
The name “Half Exterior and Half Interior” was succinctly described in “Zhu Jie Shang Han Lun” by the Song Jing Yuan practitioner Cheng Wu Ji (1063~1156 AD). In Shang Han Lun there is a subtle mention of Half exterior and half interior in Clause 148: Shang han for five or six days, if there is sweating from the head, mild aversion to cold, cold hands and feet, fullness below the heart, no desire to eat, a hard stool and a thready pulse, this is a mild yang bind, there will be both exterior and interior. A submerged pulse, it is also in the interior. Sweating indicates the mild yang; if it were pure yin bind, there would be no more exterior signs, it would have entirely entered the interior; this is half in the exterior and half in the interior”. At the time when Zhang Zhong Jing created the concept of half exterior and half interior he also clearly outlines the treatment strategy for a half exterior and half interior pattern that neither sweating or purging is indicated and the only treatment is to harmonize.
In the Shang Han Lun text, discussion of half exterior and half interior pattern is relatively lacking when compared with the exterior and interior patterns. On account that the half exterior and half interior is located between the exterior and interior tantamount to the cavity between the chest and abdomen where the body’s zang fu organs are located, hence patterns associate with the half exterior and half interior are prevalent with many complications. The author often adopts the method of elimination.
An Understanding of Half Exterior and Half Interior patterns
The philosophy of a contention between the zheng qi and pathogenic qi constitutes the core theory of Chinese medicine. There is a saying :” If zheng qi is in tact, there will be no harassment by the pathogenic qi”; the exploitation of pathogenic qi can only be on the basis that the zheng qi is deficient. In Shang Han Lun, this theory of the contention between pathogenic qi and zheng qi is reflected in the text. The manifestation of disease is the result of the struggle between the zheng qi and pathogenic qi. If the contention is at exterior then it is an exterior pattern. “Fever, aversion to cold, this stems from the yang and is a Tai Yang disease; treatment is Ma Huang Tang, Gui Zhi Tang group of formulas which are acrid and warm to release exterior. “If there is no fever but aversion to cold, it stems from the yin and is a Shao Yin disease, treatment is Ma Huang Fu Zi Gan Cao Tang or Gui Zhi jia Fu Zi Tang to strengthen the yang and release exterior.
As for the issue of contention between the zheng qi and pathogenic qi at the exterior with subsequent zheng qi failing to overcome the pathogen, this will lead to the pathogen entering the interior. Shang Han Lun Clause 97: “Blood is weak and qi exhausted, the interstices are open, evil qi enters, it vies with the zheng qi, knotting below the ribs”. This literally confirms that the transmission of diseases is from the exterior to the interior and from superficial to deep. Prior to the compilation of Shang Han Lun, the concept of exterior and interior and if a disease is not located at the exterior then it should be interior hence treatment is sweat promotion and if this is not effective then purging is used. Shang Han Lun clearly states that apart from exterior and interior there are conditions associated with half exterior and half interior.
Six channel pattern identification originated from the eight guiding principles i.e. exterior, interior, half exterior and half interior (disease location), heat and cold, deficiency and excess (disease nature) and the incorporation of yin and yang as the heading . Likewise the half exterior and half interior location can be differentiated as yin and yang by identifying Shao Yang disease as half exterior and half exterior yang pattern while the corresponding yin pattern is referring to Jue Yin disease.
By citing the three yang diseases, Tai Yang is exterior, Yang Ming is interior, Shao Yang is half exterior and half interior. Treatment for Tai Yang disease is to release exterior; while Yang Ming disease is to adopt interior heat clearing and Shao Yang disease is to harmonize the half exterior and half interior. From the symptoms perspective, Yang Ming is “stomach is replete” characterized by fever, sweating, thirst, big pulse interior excess pattern also known as Bai Hu Tang pattern or excess heat bind in the intestine with corresponding Cheng Qi Tang pattern etc. The outline for Shao Yang disease is “ bitter taste in the mouth, parched throat and dizziness” this type of heat can be classified as heat in the orifice as yet to reach the severity of Yang Ming heat and treatment is Xiao Chi Hu Tang. Huang Qin clear gallbladder heat, Chai Hu release exterior and vent constrained heat outwards; Sheng Jiang tonifies the middle, Ren Shen, Gan Cao and Da Zao prevent the further penetration of pathogen into the interior. This defines that Shao Yang is located between Tai Yang and Yang Ming and is a transitional stage between the exterior and interior.
Historically Shao Yang apart from being a half exterior and half interior pattern, it acts as a pilot between exterior and interior and plays a significant role with regards to disease transmission. The reason for pathogen harassing the Shao Yang , this is because the half exterior and half exterior is “Blood is weak and qi exhausted, the interstices are open for exploitation of pathogenic qi” and treatment for a half exterior and half interior pattern is to protect the zheng qi to prevent further transmission of the pathogen. Xiao Chai Hu Tang has Ren Shen, Da Zao, Gan Cao and Sheng Jiang while Chai Hu Gui Zhi Gan Jiang Tang for treatment of Jue Yin has Gui Zhi, Gan Jiang and Gan Cao; Wu Mei Wan has Gan Jiang, Dang Gui, Ren Shen etc. One of the drawbacks of the half exterior and half interior patterns is that there is no exit point and pathogenic constraint may often lead to transformation of heat. Therefore apart from the harmonizing strategy, heat clearing should also be incorporated to address the constrained heat.
How to diagnose a half exterior and half interior pattern:
When encountering a classic half exterior and half interior pattern which matches with Shao Yang and Jue Yin outline, it can be confirmed a half interior and half exterior pattern. If there are signs such as “rib-side fullness, bitter taste in the mouth, parched throat, dizziness and wiry pulse” this can be directly interpreted as Shao Yang disease and Xiao Chai Hu Tang pattern. As for patterns which do not present the classic features, we should then adopt the elimination process.
Unlike the exterior or interior patterns, the location of the half exterior and half interior is an area where several zang fu organs are located, diseases of half exterior and half interior can be complicated and changeable . For example symptoms such as “bitter taste in the mouth, parched throat and dizziness” does into incorporate the full spectrum of all Shao Yang disease; likewise, symptoms such as “insatiable thirst, qi upsurge harassing the heat, pain and heat in the heart, desire of hunger with no desire to eat, after ingestion of food there may be vomiting of worms or incessant diarrhoea” again do not cover the full spectrum of Jue Yin disease. At this point in time, the only alternative is to adopt the elimination process to preclude that it is neither an exterior nor interior pattern together with a follow up appraisal of heat and cold, deficiency and excess to determine whether this be a yang pattern of Shao Yang or yin pattern of Jue Yin. Once this is established one can then proceed to identify the formula pattern.
In Shang Han Lun, the sequence of the six channels in accordance with their pecking orders of Tai Yang, Yang Ming, Shao Yang, Shao Yin, Tai Yin and Jue Yin with Shao Yang being the last of the three yang channels and Jue Yin being the last of the three yin channels hence the half exterior and half interior patterns are at the end of the exterior pattern as well as interior pattern.
Zhang x female
First consultation: 15th January 2010
S/S: The patient complained of a subjective sensation of heart palpitation, shortness of breath, easily tensed with relief after sighing; fatigue, poor sleep, wake up easily at night with difficulty in falling asleep again. A subjective feeling of throat obstruction by roast meat during the night, tension in the legs, radiating pain from the lower limbs to the back of the heel, thirst, heart vexation, no sweating, scant menstruation, cold extremities, difficult bowel with blood in the stool, a thready pulse, pale, dull and big tongue body and thin tongue coat.
Discussion: The above case study is characterized by many symptoms which is difficult to determine the correct diagnosis. With the Jing Fang approach, one must identify the six channel first ahead of other form of diagnosis. The patient does not have fever and aversion to cold (exterior) and absence of constipation or sloppy stool (interior) therefore we can eliminate the exterior and interior and focus on the obvious which is half exterior and half interior. This is combined with parched throat, heart vexation, cold extremities and scant menstruation due to blood deficiency with constrained heat. The pattern is associated with a yin pattern hence it can be concluded as a half exterior and half interior yin pattern i.e. Jue Yin disease. The cold extremities and scant menstruation can be a half exterior and half interior deficient cold pattern with simultaneous transformation to heat, coupled with upsurge of water rheum characterized by heart vexation, heart palpitation, shortness of breath and poor sleep etc. Treatment is to clear heat in the upper jiao and warm coldness in the lower coupled with regulating heat and cold, nourish blood and disinhibit water rheum.
Formula pattern is Chai Hu Gui Zhi Gan Jiang Tang + Dang Gui Shao Yao San pattern.
Prescription: Chai Hu 12g; Huang Qin 10g; Tian Hua Fen 12g; Sheng Long Mu 15g each; Chuan Xiong 6g; Gui Zhi 10g; Gan Jiang 10g; Dang Gui 10g; Bai Shao 10g; Cang Zhu 10g; Ze Xie 12g; Fu Ling 12g. Seven packs.
After one week of medication, her symptoms of heart palpitations, shortness of breath, tension and poor sleep were substantially relieved. Adjust the formula accordingly during the ensuing two weeks. She recovered.
About Dr Greta Young Jie De
Greta Young Jie De is a registered Chinese Medicine practitioner with the Chinese Medicine Registration Board Australia, with a focus on the treatment of emotional disorders using Chinese medicine. She is an expert in the classic literature of Chinese… Read more »